It’s Not You or Me. It’s the Health Care System.

Milbank State Leadership Network
Focus Area:
Primary Care Transformation
Primary Care Investment

“I got bad news. My doctor and I broke up.” 

“Oh, man. What happened? I thought you guys really dug each other.” 

“Yeah me, too. I dunno. It just changed. They got real distant. I couldn’t reach them anymore. And some of it was me. Stuff happened, I moved, got a new job — and I just lost touch.” 

“That’s too bad.” 

“Yeah. I miss them. I guess I will have to start all over again — but maybe not now.” 

Healthy relationships make for healthy lives. That includes relationships with one’s regular health care provider. Compared to those without, people who say they have a regular place to go when they are sick or need medical guidance, report: 

  • Fewer emergency department visits  
  • More comprehensive preventive care  
  • More patient-centered care  
  • Higher use of outpatient services and lower use of inpatient services 
  • Better care for chronic illnesses, including behavioral health conditions. 

Having this usual source care (USC) also reduces the disparities in outcomes based on race and ethnicity that plague the US health care system. 

So, it is concerning that the proportion of people reporting no USC in the US has steadily increased over the last 20 years, even as insurance coverage has expanded (Figure 1). This trend has grave consequences for health and health equity in the United States. 

Figure 1. Percent of US Population with a USC

What do we know about establishing and maintaining these relationships? Research has shown: 

  • Location matters: the percentage of people without a USC varies by 50% percent depending on their state of residence. 
  • Income matters: people with fewer financial resources are less likely to report a USC. 
  • Race matters: people of color are persistently less likely to report a USC. 
  • Provider supply matters (mostly): having a usual source of care is loosely associated with the supply of primary care providers in a region. 

But what about the downward trend? Who is breaking up with their regular clinician and why? A new Milbank Memorial Fund report examining who is gaining or losing a USC provides evidence that can inform public policy. Using data from the US Health and Retirement Survey, which queries people over age 50, researchers at Leading Age LTSS Center at UMass Boston gained the following insights.

The declines are systemic: the portion of people reporting a USC declined steadily between 2014 and 2020, regardless of age, gender, race/ethnicity, or income (Figure 2). 

Figure 2. People Reporting a USC by Demographic Characteristic

Source: Tavares JL, Cohen MA. Becoming Less Usual: Understanding the Decline in the Number of People with a Usual Source of Care. The Milbank Memorial Fund. September 2023.

Life transitions matter: People were likely to gain a usual source of care if they developed a chronic illness or got a job. However, moving residences, becoming widowed, and becoming depressed left one more vulnerable to losing a USC. 

Managed care helps: People enrolled in a managed care plan were more likely to maintain or gain a usual source of care. 

More needs to be learned about the systemic nature of the decline in people reporting a usual source of care. Is this part of a larger trend towards social isolation? There may be associations between declines in USC and findings from sociologists about declines in community cohesiveness and individuals’ sense of belonging.  

But lest we get caught up in a public policy doomscroll, the existing evidence makes it clear: helping more people obtain or keep a USC should be a public policy goal. This research suggests there are public and private policies to attain this goal, including:  

  • Promote insurance benefit designs that encourage or require selection of a USC. The term “managed care” may carry baggage, but the principles of incentivizing preventive care and care coordination are sound. A study of public employees in California found that requiring a primary care provider (PCP) designation, making that provider inexpensive for enrollees, and encouraging wellness activities in exchange for reductions in annual deductibles resulted in fewer inpatient admissions, more PCP visits and more immunization. Employers, public payers, and insured beneficiaries need to respond to the evidence supporting having a USC, or they will continue to pay the higher costs associated with ignoring it.  
  • Strengthen the capacity and supply of primary care teams. Not only is a having a usual source of care positively associated with local primary care clinician supply, the systemic decline in people with a USC documented in this report is correlated with an overall decline in primary care clinician supply in the US over the same time period, as Milbank’s health of US primary care scorecard documented. This declining supply of primary care clinicians has reached crisis proportions.  

    The 2021 National Academy of Sciences, Engineering, and Medicine report on primary care recommends federal, state, and private sector policies in the areas of payment, access, workforce, and information technology that need to be taken to strengthen primary care. Private and public sector leaders need to prioritize these policies if we want to strengthen primary care and reverse the USC trends.  
  • Build strong communities. The regional variation in rates of people reporting a USC cannot be ignored. Having more primary care clinicians partly explains this variation, but what about places like Wisconsin, Michigan, and New Hampshire with relatively few primary care clinicians but high rates of USC (see Figure 3)? Is it possible some communities — through public policies or local culture — attend to the important life transitions identified in this research, such as job, residency, and family status changes, in ways that support individuals and families better, making them feel more connected and less isolated? 

Figure 3. Percent of Population with a USC vs. PCPs per 100,00 Population by State

Source: Jabbarpour Y. Greiner A. Jetty A. et al. Relationships Matter How Usual is Usual Source of (Primary) Care? Primary Care Collaborative and the Robert Graham Center. November 2022.

Being alone can stink. Especially when one is sick. Relationships between patients and their regular clinicians are breaking up more often these days, and that is a grave threat to our individual and collective health. The reasons are more systemic than personal. To borrow a term from public health, public and private sector actors need to make the right choice the easy choice by incenting or even requiring the selection and utilization of a usual source of care in insurance benefits, strengthening the supply and capacity of primary care providers, and supporting people in their life transitions.